Renee Butkus, BA; Katherine Rapp, BS; Thomas G. Cooney, MD; Lee S. Engel, MD; for the Health and Public Policy Committee of the American College of Physicians *
Financial Support: Financial support for the development of this position paper came exclusively from the ACP operating budget.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-2410.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Corresponding Author: Renee Butkus, BA, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001.
Current Author Addresses: Ms. Butkus and Ms. Rapp: American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001.
Dr. Cooney: Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239.
Dr. Engel: Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112.
Author Contributions: Conception and design: R. Butkus, K. Rapp.
Analysis and interpretation of the data: R. Butkus, K. Rapp, T.G. Cooney, L.S. Engel.
Drafting of the article: R. Butkus, K. Rapp, L.S. Engel.
Critical revision of the article for important intellectual content: R. Butkus, T.G. Cooney, L.S. Engel.
Final approval of the article: R. Butkus, K. Rapp, T.G. Cooney, L.S. Engel.
The American College of Physicians (ACP) has long advocated for universal access to high-quality health care in the United States. Yet, it is essential that the U.S. health system goes beyond ensuring coverage, efficient delivery systems, and affordability. Reductions in nonfinancial barriers to care and improvements in social determinants of health are also necessary. This ACP position paper calls for ending discrimination based on personal characteristics; correcting workforce shortages, including the undersupply of primary care physicians; and understanding and ameliorating social determinants of health. The ACP calls for increased efforts to address urgent public health threats, including injuries and deaths from firearms; environmental hazards; climate change; maternal mortality; substance use disorders; and the health risks associated with nicotine, tobacco use, and electronic nicotine delivery systems in order to achieve ACP's vision for a better U.S. health care system.
American College of Physicians vision statements related to barriers to care and social determinants of health.
Retired mental health editor
January 21, 2020
Belief in stigma
Stigma is a barrier to care for racial and ethnic minorities. A survey of low-income African Americans demonstrated that stigma can prevent people from seeking care for depression (44). You are missing a qualifying term: "belief in stigma".
Kevin Pezzi, MD
January 22, 2020
The ACP raised an excellent point by targeting the inexcusable reimbursement disparity between “complex cognitive care and procedural care.” In my professional lifetime, surgeons and others performing procedures were paid significantly more than those whose work primarily involves thinking, such as internists. This is indefensible. As an ER doctor, I performed numerous procedures, including surgery, as well as doing what the “thinking” specialists (e.g., internal medicine, pediatrics, neurology, etc.) do, and unquestionably the procedures and surgery were vastly easier, even fun. Surgeons sometimes defend their disproportionately greater reimbursements by mentioning how their jobs involve thinking, not just performing surgery. Indeed that is true; surgeons also deliver complex cognitive care, but to the extent they are reimbursed for thinking, why aren't the nonprocedural specialists adequately compensated for that? The latter do it, with that usually filling a greater percentage of their workweek. No matter how you dissect this issue, it boils down to how the medical reimbursement system places a higher value on surgery and other procedures and less value on complex cognitive care. It would be an interesting historical exercise to dig into this topic, searching for its roots. Having not done that, I can only speculate on its origin. One possibility is that those setting reimbursements were not doctors, as I am, who can do procedures and surgery as well as deliver complex cognitive care, and thus were unable to realize what is obvious: that thinking is the hardest work in medicine, without a doubt. It typically takes too long to right wrongs. We've seen this in the glacial pace of reversing iniquities like slavery and segregation, but we've also witnessed it in how this issue of reimbursement fairness has repeatedly surfaced in the past without fundamentally solving this inequity. This perennial neglect stems from how, as Voltaire observed, “No snowflake in an avalanche ever feels responsible,” so those in charge of dividing the healthcare reimbursement pie kick the can down the road or make trivial concessions. Ultimately, this issue isn't just about fairness for physicians but also their patients, who are shortchanged by the erosion of support for complex cognitive care.
Butkus R, Rapp K, Cooney TG, et al, for the Health and Public Policy Committee of the American College of Physicians. Envisioning a Better U.S. Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health. Ann Intern Med. 2020;172:S50–S59. doi: https://doi.org/10.7326/M19-2410
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Published: Ann Intern Med. 2020;172(2_Supplement):S50-S59.
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